Knowledge About HIV/AIDS and its Transmission and Misconception Among Women in Thailand

Purpose

Human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS) has become one of the world’s most serious public health challenges in recent years. According to the United Nations Programme on HIV/AIDS (UNAIDS),1 there were 37.9 million people globally living with HIV in 2018, which was 3.3% higher than 2015. In 2022, about 39 million people globally had HIV, including 37.5 million adults and 1.5 million children (<15 years). Women and girls made up 53%. While 86% of people with HIV knew their status, 14% (5.5 million) still required testing services.2 Globally 46% of all new HIV infections were among women and girls in 2022. HIV testing is an essential gateway to HIV prevention, treatment, care, and support services. The global target for HIV status awareness is 95% by 2025.2 Asia ranks second only to sub-Saharan Africa in terms of the number of people living with HIV. The United Nations (UN) has set a Sustainable Development Goal (SDG) target to end AIDS as a public health threat by 2030. Thailand stands out as one of the most severely affected countries in the Asia-Pacific region regarding HIV prevalence, with 1% of adults aged 15 to 49 living with HIV in 2020, compared to less than 0.1% in neighbouring countries like Bangladesh, Mongolia, New Zealand, and Sri Lanka.1^,3^,4 Thailand is one of the Asian countries that have been most impacted by the epidemic of HIV/AIDS.5^,6 Regardless of continuous widespread international efforts, the epidemic of HIV/AIDS has survived more than 4 decades with higher prevalence in low and middle income countries (LMIC), and still remains a threat to millions of lives and destabilizes the development of the vulnerable countries.7^-9 Specifically, Thailand has made notable progress through prevention programs but continue to face significant challenge, with over 440 000 people living with HIV and thousands of deaths due to HIV annually.10

The 2016 UNAIDS political declaration aimed to reduce new HIV infections to under 500 000 globally by 2020. A key target was ensuring 90% of young people had the knowledge, skills, and access to sexual and reproductive health services to protect themselves, reducing new infections among adolescent girls and young women to under 100 000 annually.11 One of the key indicators for achieving Sustainable Development Goal 3 (SDG3), set by the World Health Organisation (WHO) in 2015 is to end AIDS as a public health threat by 2030.12^,13 However, the current trend suggests otherwise.14^-16 HIV remains a significant public health issue in Thailand despite the successful preventions in the early to mid-1990s and the expansion of access to antiretroviral therapy (ART) in the 2000s. Data from the HIV sentinel surveillance system (HSS) and surveys among key affected populations and the general population suggest the continued spread of HIV and ongoing risk behaviours.17

Misconceptions are a significant barrier to controlling the spread of AIDS. They contribute to negative attitudes towards those affected by the disease, potentially causing serious harm to both their physical and emotional well-being.18 Providing accurate information about HIV/AIDS is the first step towards raising awareness among the general public, which in turn can help people protect themselves from HIV infection. This strategy aligns with the Global AIDS Monitoring (GAM) reporting indicator provided by UNAIDS,11 which has shown that the percentage of young people who have comprehensive and correct knowledge of HIV prevention and transmission, is defined as (1) knowing that consistent use of a condom during sexual intercourse and having just 1 uninfected faithful partner can reduce the chance of getting HIV, (2) knowing that a healthy-looking person can have HIV, and (3) rejecting the 2 most common local misconceptions about transmission/prevention of HIV/AIDS. HIV/AIDS related knowledge and education are seen by many as central to increasing people’s awareness of, as well as decreasing their vulnerability to HIV/AIDS.19^-22 Previous studies have shown that the prevalence of HIV/AIDS is significantly higher among individuals who are unaware of the potential routes of transmission due to lack of sexual education.23^-26

Studies suggest there are many potential factors that are attributable to the increased risk of HIV/AIDS infection and/or transmission. Such factors include sexual education, education, poverty, place of residence (urban/rural), gender inequity, migration, knowledge about HIV/AIDS, ethicality and exposure to media.21^,27^-32 Studies have found that sexual education has a significant positive effect on knowledge and attitudes about HIV and its transmission.19^,33^-35 Women from male-headed households often have less knowledge about HIV/AIDS and a greater belief in myths and misconceptions. This may be due to gender inequality, as women in male-headed households often have less freedom to participate in adult health education and are subjected to societal subordination, which influences the societal response to female drug users.9^,19^,36^,37 Evidence indicates that the primary modes of HIV/AIDS transmission include unprotected sexual contact, intravenous drug use with contaminated needles, blood transfusions, and vertical transmission from mother to child.38 However, there remains significant misconception about how HIV/AIDS is transmitted.39

Several studies have examined HIV/AIDS knowledge, attitudes, and misconceptions among women in Asia, including Thailand. However, research on how sexual education and educational status affect HIV/AIDS awareness and misconceptions, using path analysis and socio-demographic mediators, is lacking. Such insights could guide interventions to achieve SDG3 by 2030. Identifying vulnerable cohorts at risk of HIV is crucial for efforts in prevention, treatment, care, and support. Therefore, this study aimed to conduct a path analysis using structural equation modelling to examine the complex associations between sexual education, educational status, and women’s knowledge about HIV/AIDS (awareness), transmission, and misconceptions, while investigating the mediating factors and identifying the most vulnerable group of women in Thailand.

Theoretical Framework

Various theories and models have been used in health communication campaigns to assess changes in behaviour, particularly regarding HIV/AIDS. Early in the pandemic, approaches based on the Health Belief Model (HBM), Theory of Reasoned Action (TRA), and AIDS Risk Reduction Model (ARRM) were prevalent. These models emphasize knowledge and behaviour in minimizing HIV/AIDS risk. The current study’s framework is based on HBM, positing that individual actions are influenced by perceived threat and benefits of addressing the disease.40^,41 According to the HBM, it is hypothesized that in order to adopt recommended health behaviors, individuals must be aware of the potential negative outcomes, such as understanding how HIV/AIDS is transmitted and the methods of its prevention.41^-43 This model has been used in previous studies on HIV/AIDS prevention to address knowledge about HIV/AIDS, transmission methods, and related myths and facts.19 This study aims to examine how women’s perceptions of HIV/AIDS in Thailand are influenced by their knowledge of sexual education and various socio-demographic factors, such as level of education, area of residence, number of children, household wealth index, and marital status, by evaluating MICS data. In line with these objectives, the theoretical framework of the HBM19 was adopted for this study (Figure 1).

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Methods

Results

In the MICS 2022 survey, data from 3671 Thai women were available for analysis. The women in this study had a mean age of 19.61 years (SD = 3.01). About 51.1% of the women lived in urban areas, while the rest lived in rural areas. A significant portion (47.5%) of the women had completed upper secondary education, 26.6% had completed primary or lower secondary education, and 25.9% had reached higher education. More than half (66.1%) of the women were single, while 9.9% were married and 24% lived together with a partner. Approximately 71% of women did not have children, and most households (52.6%) were headed by males. Approximately 70% of the household heads had completed only primary or lower secondary education, and the majority were over the age of 50 years. Most of the women (91%) had received sexual education. Supplemental Table 1 provides a detailed breakdown of sociodemographic variables (Suppplemental Table 1).

Each of the 6 questions was answered accurately most of the time (78.9-98.8%) (Table 1). However, only 62% of respondents answered all 6 questions correctly.

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Table 2 presents the unweighted bivariate association between women’s knowledge about HIV and various socio-demographic factors. Several Chi-square tests of independence were performed to examine the relationships between knowledge about HIV/AIDS and categorical socio-demographic variables. The results reveal that women’s knowledge of HIV is significantly associated with several variables, including their level of education (X²(2) = 11.273, P = .004), wealth index (X²(4) = 28.846, P < .001), marital status (X²(2) = 37.744, P < .001), number of children (X²(1) = 28.857, P < .001), and knowledge of sexual education (X²(1) = 16.502, P < .001). Based on the values of Cramer’s V, marital status, wealth index, and the number of children show a strong association with women’s knowledge of HIV/AIDS (Table 2).

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Socio-demographic factors, such as women’s and the household head’s education, marital status, wealth index, number of children, area of residence, and gender of household head, have been integrated as mediators in the SEM, with pathways outlined in line with earlier research. Variables not associated with women’s knowledge of HIV, such as age and the age of the household head, were excluded from the SEM. Figure 2 shows the path diagram of the final adjusted fitted SEM. The main predictor in our model is sexual education, which influences the outcome variable, knowledge about HIV/AIDS and its transmission and misconception, through several mediating variables. Notably, the model fit statistics ( RMSEA = 0.024, CFI = 0.998, TLI = 0.988, SRMR = 0.011) show an excellent fit to the data.

Table 3 summarizes the final adjusted SEM, showing path coefficients and P-values for the direct and indirect effects on women’s HIV knowledge. Sexual education (β = 0.051) and higher household wealth (β = 0.070) positively impact HIV knowledge and misconceptions. In contrast, marital status (β = −0.068) is negatively associated, indicating that married women are less likely to have accurate knowledge about HIV/AIDS and its transmission.

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Sexual education is positively linked to education level (β = 0.135), wealth index (β = 0.066), household head’s education (β = 0.059), and female-headed households (β = 0.033). Women receiving sexual education tend to have higher education, wealth, and educated household heads. Conversely, sexual education is negatively associated with number of children (β = −0.023), urban residence (β = −0.051), and marital status (β = −0.046), indicating women without it are more likely married with more children and living in urban areas.

Women’s education is positively linked to household wealth index (β = 0.192) and area of residence (β = 0.068), while negatively associated with the number of children (β = −0.106) and marital status (β = −0.277). This indicates that more educated women tend to have fewer children and are more likely to be single. The education level of the household head positively correlates with women’s education (β = 0.335), wealth index (β = 0.249), urban residence (β = 0.170), and female-headed households (β = 0.109). This suggests that higher household head education leads to better educational opportunities for women, increased wealth, and a tendency to live in urban areas. Women’s area of residence negatively associates with marital status (β = −0.063), indicating urban living is linked to being single. The gender of the household head negatively correlates with wealth index (β = −0.095), while positively associating with urban residence (β = 0.066).

As shown in Table 4, the final SEM model reveals significant indirect effects based on bootstrap analysis. Figure 2 illustrates several full mediations between women’s sexual education and their knowledge about HIV/AIDS. The relationship between women’s education and HIV knowledge is fully mediated by household wealth and marital status. Household wealth also mediates the links between number of children, household head’s education, gender of the household head, and HIV knowledge/misconceptions. Additionally, women’s marital status fully mediates the relationship between area of residence and HIV knowledge/misconceptions. Similarly, the relationship between household head’s education and HIV knowledge/misconceptions is fully mediated by women’s education level. Significant partial mediations were also identified, particularly the relationships between sexual education and knowledge and misconceptions on HIV/AIDS through marital status and wealth index (Table 4 and Figure 2). Supplemental document (Table 2) shows details other partial mediations.

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Discussion

In this study, data from the latest nationally representative MICS conducted in 2022 were analyzed to identify predictors of poor HIV/AIDs transmission among women living in Thailand. This study estimate the portion of women who were vs were not knowledgeable about HIV/AIDS transmission, and examined the direct and indirect associations of knowledge status with sociodemographic factors through SEM analysis. The findings demonstrated strong evidence of direct, indirect, and mediating effects of women’s sexual education and education status on knowledge about HIV/AIDS. The results revealed that overall, 62% of Thai women reported having accurate knowledge about HIV. Poor knowledge was more likely for women without sexual education, living in households led by an illiterate head, residing in rural areas, belonging to the poorest wealth quintile, and having a low level of education.

These findings are consistent with previous literature.19^,50^,51 As anticipated, consistent with previous studies and the Health Belief Model (HBM), this study found that several sociodemographic factors—including education level, wealth index, living area, gender of the household head, number of children, and marital status—mediated the relationship between the primary predictor, sexual education, and knowledge about HIV/AIDS.52^-55

This study reveals that women’s sexual education, wealth index, and marital status significantly impact HIV/AIDS knowledge, supporting previous research that highlights these sociodemographic factors as key predictors.52^-54^,56^,57 As expected, sexual education and education are the key drivers in the knowledge of HIV/AIDs in women, as educated women are expected to be more concerned about their health and their newborn child as compared to their uneducated counterparts.19^,58^,59 As addressed in past literature, it is expected that women with institutional education would understand the concept of how a virus spreads, comprehend the deadliness of sexually transmitted diseases (STDs) and so render awareness.41^,60^,61 Studies have emphasised that to reduce the risk of infection among young women, the most important thing is to promote comprehensive sexual education.33^,52 The structural equation model reveals that sexual education directly improves knowledge of HIV/AIDS and its misconceptions. Women’s education impacts HIV knowledge, fully mediated by household wealth and marital status. To enhance HIV/AIDS knowledge, it’s crucial to educate women and provide sexual education, considering factors like wealth, marital status, and area of residence.

Studies have highlighted that married women are more likely to be exposed to misconceptions about HIV/AIDS transmission compared to never-married women, as observed in this study of married women in Thailand.18^,62 Similarly, married women are at a higher risk of HIV/AIDS due to a range of structural barriers and contextual gender inequalities, including poverty, economic disempowerment, cultural inequities, increased risk of sexual violence, gender power imbalances in sexual interactions, and traditional beliefs about HIV/AIDS knowledge and its transmission.63^,64 Misconceptions about HIV/AIDS transmission and a lack of knowledge about the disease were found to be less prevalent among women in rural areas compared to those in urban areas. This finding is consistent with other studies conducted in China, Malawi, Ghana, and Bangladesh,18^,19^,62^,65^,66 possibly due to inhabitants of these regions possessing limited information about how HIV/AIDS is transmitted. However, rural women were less likely to believe that HIV/AIDS could be transmitted through witchcraft or supernatural means, a result that warrants further investigation using qualitative data.

While the household head’s education did not directly affect women’s HIV/AIDS knowledge, its impact was fully mediated by the women’s education level. Women in households where the head had primary or higher education showed significantly greater HIV/AIDS knowledge, supporting previous research that views education as a “social vaccine” against HIV/AIDS.19

Educated women are more likely to live in urban areas and be wealthier, yet their ability to identify HIV myths and misconceptions is indirectly influenced. Sexual education significantly correlates with the wealth index, which indirectly affects knowledge about HIV/AIDS myths, aligning with previous studies.19^,58 As hypothesized in the conceptual framework, the effects of sexual education on knowledge and understanding of myths and misconceptions about HIV/AIDS was mediated through women’s wealth index. This study found that respondents in the richest quintile had better knowledge and understanding of myths and misconceptions about HIV/AIDS than respondents in the poorest quintile. A possible explanation is that HIV/AIDS is considered a disease of the poor. Poverty increases risky behaviour towards HIV/AIDS such as transactional gender. Poverty also leads to fewer opportunities for work and education. On a broader scale, financial shortfalls can limit educational opportunities, access to health care, and access to jobs. These conditions create a favourable environment for the spread of HIV/AIDS.67^,68

In summary, this study found that education and sexual education were important predictors of knowledge about HIV/AIDS. Improvement in education and sexual education are likely to assist Thai women to be better informed about HIV transmission, which in turn is likely to reduce new cases of HIV/AIDS, consistent with the SDG goal.46^,69^-71

To our knowledge, this is the first study to utilize the most recent MICS (2022) data—a relatively large and representative dataset—to assess the direct and indirect impact of sexual education and educational attainment on HIV/AIDS knowledge and awareness among Thai women, using path analysis through an SEM approach. However, this study had several limitations. First, the HIV/AIDS data from the MICS were based on self-reported information, which may be subject to recall bias. Second, the responses regarding HIV/AIDS knowledge, transmission, and misconceptions were dichotomous, such a binary approach may have oversimplified knowledge status, and that by a continuous measure of knowledge may be a better indicator of knowledge of HIV/AIDS. Third, women who had never heard of HIV/AIDS were not asked about transmission or misconceptions, significantly reducing the sample size in the latter part of the analysis, which requires careful interpretation. Fourth, since the MICS surveys are cross-sectional, causal associations cannot be established. Fifth, although women’s education was assessed, health literacy could not be evaluated due to limitations in the survey data, which might be more relevant for understanding health awareness. Sixth, due to the absence of qualitative data, the generalization of the findings should be approached with caution. Finally, women’s empowerment and media exposure were not included in the analysis due to limitations in data availability. Future studies or surveys could consider addressing this issue.

To enhance knowledge and address misconceptions about HIV/AIDS transmission among married women in Thailand, policymakers should consider implementing effective intervention programs that focus on factors indirectly influencing HIV/AIDS awareness, rather than relying solely on sexual education and/or education. Strengthening educational initiatives alongside sexual education could play a crucial role in fostering knowledge and awareness among the younger generation. Additionally, health promotion and gender equality programs involving community participation could be highly effective in Thailand, where women’s autonomy remains limited. Moreover, the government plays a crucial role in reducing stigmatizing attitudes toward HIV/AIDS transmission by promoting accurate information and fostering understanding among youth through partnerships with health professionals and public figures.

Future research should adopt a more in-depth approach using a mixed-methods study design at the population level, incorporating mediating factors alongside the primary predictors of HIV/AIDS knowledge. Additionally, studies should emphasize a co-design approach by involving community members in the research design process.

Conclusions

In the dynamic social settings of LMICs including Thailand, it is necessary to gather vital evidence through mixed-method research to empower women with sexual education along with education, alongside achieving broader goals including the SDG3 by 2030. The direct and indirect effect of sexual education, education, residence, wealth index and husband’s education on knowledge and understanding of myths and misconceptions about HIV/AIDS outline the complex mechanisms of various sociodemographic factors on Thai women’s knowledge about HIV/AIDS. In summary, this study’s findings support previous studies examining the influences of sociodemographic characteristics on knowledge and understanding of myths and misconceptions about HIV/AIDS. The findings indicated that there were multifaceted scopes for improvement in increasing awareness about HIV/AIDS and clarifying misconceptions regarding the mode of transmission of HIV/AIDS through a path analysis approach. Strengthening educational programs along with sexual education could have great importance in fostering knowledge and awareness among the younger generation.